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When assessing a child with HIV, which system should the nurse assess first?
- A. Assess the respiratory system.
- B. Assess the gastrointestinal system.
- C. Assess the cardiovascular system.
- D. Assess the neurological system.
Correct Answer: A
Rationale: When assessing a child with HIV, it is essential to prioritize assessing the respiratory system first. Children with HIV are more susceptible to respiratory infections and complications, such as pneumonia, due to their weakened immune system. Identifying any respiratory issues early on can help in prompt intervention and management, thus improving outcomes for the child.
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A 6-year-old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is more important for the nurse to implement?
- A. Graph the daily weight for the past week.
- B. Decrease IV flow rate.
- C. Assess bilateral lung sounds.
- D. Restrict intake of oral fluids.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 28-year-old client in active labor complains of cramps in her leg. What intervention should be implemented?
- A. Massage the calf and foot.
- B. Extend the leg and dorsiflex the foot.
- C. Lower the leg off the side of the bed.
- D. Elevate the leg above the heart.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When teaching a gravid client how to perform kick (fetal movement) counts, which instruction should the nurse include?
- A. If 10 kicks are not felt within one hour, drink orange juice and count for another hour.
- B. Count the movements once daily, for one hour, before breakfast.
- C. Avoid caffeinated drinks for 24 hours before conducting the kick test.
- D. Exercise for 15 minutes before starting the counting to help increase fetal movement.
Correct Answer: A
Rationale: When teaching a gravid client about kick (fetal movement) counts, the nurse should instruct them that if 10 kicks are not felt within one hour, they should drink orange juice and continue counting for another hour. This instruction is crucial as a drop in fetal movements could indicate potential issues with fetal well-being, and taking action such as rechecking after food intake is recommended to monitor the situation closely.
An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound infant 12 hours ago is reporting a severe headache. The client's blood pressure is 110/70 mmHg, respiratory rate is 18 breaths/min, heart rate is 74 beats/min, and temperature is 98.6°F (37°C). What action should the charge nurse implement first?
- A. Notify the healthcare provider of the assessment findings.
- B. Administer analgesics as prescribed.
- C. Increase the client's fluid intake.
- D. Monitor the client's vital signs every hour.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A one-day-old neonate develops a cephalohematoma. The nurse should closely assess this neonate for which common complication?
- A. Jaundice.
- B. Poor feeding.
- C. Brain injury.
- D. Hypoglycemia.
Correct Answer: A
Rationale: A cephalohematoma is a collection of blood between the skull and the periosteum. As the blood breaks down, there is an increased risk of jaundice due to the release of bilirubin from the breakdown of red blood cells. Jaundice is a common complication associated with cephalohematoma in neonates. Therefore, the nurse should closely monitor the neonate for signs of jaundice and manage it accordingly.